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` • �AR 2 0 2013 ���E�V�D
NOTICE OF CLAIM FOI�'��e� of Saint Pau1,hC�iB��a
Minnesota State Statute 466 OS states that "...every perso»...who clai�ns damages fram any municipality...s�,�ci�e����ited to the
governing body of the municipaliry within 180 days a,�ter the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demanded"
Plexse compiete this form in its entirety by clearly typing or printing your answer to each question. If more apace is
needed,attach additionai s6eets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to egplain your claim,and tLe amaunt of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of yoar claim. This form must be signed,and both pages completed. If aom�thing does not appty,write°N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �.s"e-� f ��'-- Middle Initial�Last Name �� 4-� � �
Company or Business Name
Are You an Insurance Company? Yes/ To If Yes,Claim Number?
Street Address � �Ss� � I'���/v iA t�� �
,
City �, �, �a�^� � State ���rV Zip Code 5� �
Daytime Phone(�51 )�.'-F � �0 Cell Phone(_) - Evening Telephone�)��� �� ;�;�
Date of Accidend Injury or Date Discovered Time `-3 ' �a__ am/ m
Please state,in detail,what occurred(happened),and why yon are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your damages. ,��� �.1vc w- L f
Y.�ILG�h�..� ya�G �,���?���.. � 5�1��� �1JIL L�Wd azV�t:.tJ`� �d�tN` b�-G\1��.. LJ��<'�'
fYl�ia, � �� h�t Z i ���.� 5�l: ` c��� � �1� i.,�( �a; y� .SN�✓�k�� �v iG� a�� jo�CC;�� �a�,rl'C,�1. .1._.
iiv� r �� � � ` � • ��c�. w1F1'C "k :5 "r�nc(�� � r � � .�' �!�. � !
I.. �'1�� �1� i.'. ''1'r'W-t 4�k�. 1.'-1 � �\ ft�L -1 � Y' ' •�2 -� -1 � �/ rC. -�'11YjM1
� I �z\ �Jtv� � � L� � ,> ��� !� .� /I .; - ,✓� � •
Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
�My vehicle was damaged by a pothole or condition of the street 0 My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property
❑Other type of property damage—please specify
❑Other type of injury—please specify
In order to process your claim you need to include coaies of a11 a�nlicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
YZ�Properiy damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other praperty damage claims:two repair estimates if the damage exceeds$500.00;or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your ctaim.
All Claims—p,�,ease complete� is section
Were there witnesses to the incident? Yes No Unknown (circle)
Provide their names,addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,crass street,intetsection,name of park or facility,
closest landmark,etc, Please be as detailed as possible. If necessary,attach a diapram. C.�r�1�c►•- a -F-
�
�a t i,-'1-��r.� �C n� �,1� �,z.,... '�� i=f<r c 5 S S���� �" -4�r�i� I Z e�? �'.«� �i.-
Please indicate the amount you are seeking in campensation or what you would like the City to do to resolve this claim
to your satisfaction. � � ti 3�,L
Vehicl aim — lease c m te thi io ❑ heck box if this sec ' does n a
Your Vehicle: Year 2�'o� Make S� w �r� Model � �
License Plate Number ST� �` State 1'Vlw• olo �J�c-'
Registered Owner_�- �,�, 14va 4-E / �����+� �.'>>Y��
Driver of Vehicle�,��,,�` 1�-�w t- �
Area Damaged �' ,�,.r� -�'��� �4 v c w
City Vehiale: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Injurv Claims please comulete this sectfon Cl check box if this sectian does not annlv
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment7 Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work7 (provide date(s))
Name of your Emptoyer.
Address Telephone
C]Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledg� Unsigned forms will not be processed
Submitting a false claim can resaCt i�prosecutio». Date form was completed `��" ��" Zv 1�
Print the Name of the Person who Completed this Form: e c� J' �- �
Signature of Person Making the Claim: %
Revised February 2011
)3-16-2013 3:57 PM DISCOUNT TIRB PRICE QIIOTS PAGE 1
� QUOTE # 38306
CUSTOMER INFORMl�TION Vffi3ICLE INFORMATION STORS LOCATION
------------------------------------------------------------------------------------
3EORGE PFAFF 2000 SUBARU MNM 05
L281 KENNARD LEGACY 2570 WHITE BEAR AVENUE N
SDN/WGN GT MAPLEWOOD MN 55109
3AINT PAUL MN 55106 PHONE: 651-773-2067
(H) 651-774-8888 PLATE # UNICNOWN
MILEAGE: UNKNOWN 493 ERIC A WICK
TORQUE SPECS: 075
CODE CC QTY SIZB DESCRIPTION F_E.T_ PRICE AMOUNT
--------------------------------------------------------------------
34362 NRM 4 205/55R16 91T BSW MICH DEFENDER AS .00 120.00 480.00
WARRANTY: MILEAGE- 90,000 WORKMANSHIP/MATERIALS-LIFETIME
COMMENT: BOLT PATTERN: 5-100
COMMENT: INFLATION F:32
30224 NRM 4 WASTE TIRE DISPOSAL FEE .00 3.00 12.00
30219 NRM 4 INSTALLATION & LIFETIME SPIN BALANCING .00 16.00 64.00
30402 NRM 4 VALVES, ROTATIONS & LIFETIME REPAIRS INCLUDED .00 .00 .00
59655 NRM 1 16X6.5 5-100/115 41B UNIQUE 83-66518 .00 65.00 65.00
WARRANTY: LIFETIME STRUCTURAL AND 1 YEAR FINISH
Tp,X; 43.39
TOTAL: 664.39
FREE CUSTOMER FLAT REPAIR AND ROTATION
This quote is good for 30 days
THANK YOU FOR SHOPPING DISCOUNT TIRE CO.
(Salesman's Signature)
)e�rs 6122 - Sears, Roebuck and Co. 3001 White Bear Ave. ESTIMATE
JTO CENTER Maplewood, MN 55109 (651) 770-4228
EPA Number:MND 068190982 Facility Number:
_:JURSIK,BRENDA TAG# INITIAL ESTIMATE REVISED ESTIMATE PHONE AUTHORIZATION REF NUM
1281CANARDST YEAR/MAKEIMODEL PARTS $57692 ES6204097
ST PAUL.MN 55106 2000 SUBARU LEGACY WAGON AWD 4-2457cc 2.SL DOHC M
UCEN E N COLOR LABOR $59 96 APPROVED 8Y: CREATED BY
(651)774-8888 GYG225 GREEN ��� 678011
V.I.N. LOCATION i-��-�--_—
— TAX $41.11 � CONTACTED BY: INVOICED BY'
INSTALLATION INSTRUCTIONS ODOMETER IN ODOMETER OUT �
TOTAL $677.99 �
Rf
TIME IN TIME OUT DATFITiME OF A?E/TIME REVISED NUMBER CALLED: LOCAL
PURCHASE
SP PO NUMBER:
03116/2013 0228 PM 2�097
PROMISED TIME �,�,;, DATE/TIME CALLED:
RR � �
�RESSURE FRONT I REAR WHL TORQUE SPECIFICATION See reverse for important warranty terms
-AL�O.E.APPLICATIONS HND TOR/58-72-ALL O.E.APPLICATIONS and other information.
MENTSIRE�UESTS OR ALTERNATE CONTACTS:
pTY ITEMk DESCRIPTIONOFMERCHANDISE PRICEEACH TOTAL TECH CSA This is an ESTIMATE
4 PS 09578168 TIRE,2256016T DEFENDER B $137.74 $550.96 T 678011
4 AC 189021 LOCALTIRE DISPOSAL $2.50 $t0.00T 678017 price for the goods and/or
4 PS 09598734 VALVE,CHR SLV 1251N $3.99 $15.96T 678011 services you have requested.
4 LB 19012005 TIREBALANCE,PERFORMANCE $14.99 $59.96 678011 These prices are good for
- A 15%Restceking Fee may appry on retumed merchandise. A 15%Cancellation Fee may apply on Special Ordered merchandise 21 days,except sale prices,WhICh 8fe
,cel�ed after 2a nours. see salesperson rorderai�s. valid for the duration of the sale.
�; ,( �j �� � j��� -- ( ��j Thank you for shopping with us!
�"�
M/WARRANTY INFORMATION I LABOR DETAILS I COMMENTS ALL NEW.NON-OEM PARTS UNLESS OTHERWISE SPECIFIED.
�rmarket TPMS Available.Verily TPMS.
:M COMMENTS:
)12005:For ihe Life of Ihe Tire,to address an uneven or imbalanced tire,we will:adjust tire pressure, remove old weights,computer spin balance Priced EACH
L LUG NUTS ON CUSTOM AND ALLOY WHEELS MUST BE RE-TOR�UED AFTER 25 MILES AND CHECKED PERIODICALLY.
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